Community Critical Care

It's been interesting seeing the span of patients admitted to the intensive care unit at a county hospital as opposed to a tertiary academic medical center. While some cases - the older nursing home patient arriving with septic shock from a urinary tract infection, the severe pneumonia requiring an artificial breathing tube - are the same, many are quite different. I've seen more patients with diabetic ketoacidosis here in a few weeks than I have the past ten months. I've seen more methamphetamine use, more intentional overdoses, more end stage cancer. The microcosm of a hospital's patients is simply a reflection of the community. Here, we see patients who cannot fill their prescriptions. They run out of insulin. They run out of food. They have nowhere to sleep. They have no family, no friends. We see patients who are plagued with voices. They are victims of domestic violence, victims of abuse. They are addicted to street drugs and no matter how much they want to quit, cannot escape an environment that has no exits. Our patients have criminal histories, altercations with police, restraining orders. They have no identity, come in unconscious, and push our social worker's finesse. We've identified patients based on bank account numbers from scraps of paper in their pocket. We've identified patients by asking the sheriff's office to fingerprint them. Our patients don't have regular doctors. They are immigrants, they are migrants, they are uneducated, they are poor, they are minorities. They are the ones we hope to help with universal health care. They are the ones who are at the most need for care, at the fringes of society, the vulnerable and the sick. They physicians who work here gravitate towards caring for these in need, and I am awed to see their dedication and passion.

Medicine and disease are intensely social phenomena. We in the ivory tower like to forget this. We think it is about advanced diagnostics, minimally invasive procedures, targeted therapies, personalized medicine. But, in the real world, it is more about where you live, whether you feel safe, your education, your financial security, your job, your vices, your psychiatric diseases. We see so many patients who are here for their fifth, sixth, tenth time of diabetic ketoacidosis. Some leave once they feel better against medical advice, and I wager we will see them again when they neglect to take their insulin, fall to using drugs. Others I hope we can salvage; one man has nowhere to store his insulin, which must be refrigerated. We hope our social worker can place him in a board-and-care that can maintain his medications. Another immigrant who has never seen a doctor in the U.S. begins to understand his diagnosis of diabetes, and we connect him to a primary care physician who speaks his language. The safety net we throw is not just medical stabilization, it is milieu of all the other things that matter more to the patient and matter more to his health. It shines a light on why it is so challenging to improve health outcomes outside the sterile lab. There are too many factors, too many variables that we cannot control.

At Stanford, I will learn to care for those tertiary center referrals, the bone marrow transplants, the rare malignancies, the enriched population of complex medical problems. But I am slowly beginning to understand how to care for the man who walks in off the street, whose medical problems are far simpler than his psychosocial circumstances.

Wedding in the Intensive Care Unit

There are a few things you don't see often. The other day, we had a wedding ceremony in the intensive care unit. The patient and her husband had been legally married several months earlier but had been saving money for a ceremony. Unfortunately, she developed a devastating infection which resulted in life-threatening respiratory failure. She had been on a breathing machine for over a week when they decided simply to hold the ceremony in the intensive care unit. With a Catholic priest dressed in a yellow isolation gown and a handful of friends and family, they held a quiet and heartfelt ceremony in the corner room of the ICU. The patient wasn't able to participate greatly because of her grave disability, but given that her chances of pulling through are small, we were glad to help them organize this ceremony. It was a tender, poignant moment that reminded me that there can be much richness even in the scariest of times, so much left at the end of life, and so much in the hospital that is not medicine.

Book Review: The Bees

I got a recommendation to pick up Laline Paull's The Bees, a fascinating book from the perspective of a small worker bee. It creates a vivid world of hierarchy, religion, communication, and economy within a beehive. The main character is a bee whose DNA codes strange mutations, allowing her to break out of her designated roles. It is a story of how she overcomes the strange social, societal, and religious boundaries of this beehive. It is also a story of the life cycle of bees, the changes of the seasons, and the threats bees face. Ultimately, it was amusing and engaging with a touch of science fiction and social commentary. However, it had the feel of a first novel without the polish of experience and time. Although I enjoyed it, it is not a book I would find myself rereading.

Image from goodreads.com, shown under Fair Use.

Santa Clara Valley

This month, I'm rotating down at Santa Clara Valley Medical Center. We only spend one month of our ICU rotation down here but I've really been enjoying it. Coming back to Valley brings back a lot of memories even though I've only spent a month or two each year here as a resident. It's really a unique and wonderful place. In particular, I miss taking care of the underserved. The county hospital takes care of so many people in need, and this month, I've seen many homeless patients, victims of domestic abuse, and undocumented migrant workers. The underserved patient population makes the medicine fascinating as well; this call, I admitted three patients with HIV. It surprises me that I can so easily forget about the underserved. After spending most of the year at the mothership, Stanford, where tertiary care problems abound, I forget what the community and county setting is like.

The month is exhausting because along with the commute, we spend a lot of time here including taking thirty hour calls. The service usually totals 10-20 patients but it is very much resident run. There are four teams with a resident and intern each, and two fellows who help out. It's a fun role to act as a consultant, supervisor, and teacher. We also help out with cardiac patients which gives me exposure to cardiac ICU problems like heart attacks and arrhythmias. The cases are quite varied, from unusual infections (M. kansasii in the blood) to uncommon overdoses (beta blocker) to rarely-seen end stage diseases. Overall, it's a great exposure for our training.

Image is in the public domain, from Wikipedia.

Transvenous Pacemaker

A woman being worked up for other medical problems develops a supraventricular tachycardia, an arrhythmia where her heart is racing. She is given some beta blockers to slow her heart rate, but they work too well, and she goes into complete heart block. The atria which normally send signals to the ventricles to contract stop communicating. Her heart beats a rate of 30. A rapid response team is called within the hospital, and a cardiologist determines that she will eventually need a permanent pacemaker. For now, she will need a temporary pacemaker.

She is sent to my service in the intensive care unit, and the cardiologist asks us to place a temporary transvenous pacemaker. I'm pretty excited since this is a rare procedure and one of the few opportunities I've had to place a pacemaker. While it's not needed frequently, when the need comes up, I need to know how to put one in.

In fact, the procedure is not all that difficult or different from other lines I've placed. After placing a 5 French introducer sheath into the right neck, I float the pacemaker into the patient's internal jugular vein, superior vena cava, right atrium, and then the right ventricle. The balloon-tipped catheter follows the flow of blood returning from the head to the heart. By using an electrode at the end of the catheter, I can track the electrical activity of the heart and determine where we are. As this one proved a little tricky, we actually got fluro to help us. We used real-time X-ray to follow the path of the pacemaker until it found an effective location in the right heart. When we applied external electrical impulses, the heart followed. That way, we could speed it up as fast as we needed. It gave us peace of mind that her heart block would not be a problem while we scheduled her for the placement of a permanent device.

Image of transvenous pacemaker components shown under Fair Use, from calsprogram.org.

Ambulance Ride

Stanford's cancer center is an interesting entity. It's physically connected to the main hospital by a skybridge but technically counts as a freestanding outpatient center. When a code is called in the cancer center (most commonly in the infusion treatment center where outpatients get chemotherapy), the inpatient code team (including myself) responds. At the same time, the staff usually calls 911 as is the policy in any freestanding outpatient center. The Palo Alto Fire Department usually responds.

When I arrive at the code, a patient who has received a bone marrow transplant for malignancy is getting ongoing chemotherapy. He has a rapid supraventricular arrhythmia. After making a few interventions to make him more stable, I know that he will need more workup: labs, imaging, studies, and consultations that we cannot provide in the cancer infusion treatment center. As he's currently an outpatient, he will need to go to the emergency department for evaluation. Strangely, though, the protocol is to take the patient to Stanford's emergency department by ambulance. Though it requires more resources, it's probably more efficient than going across the skybridge and down to the emergency department.

Since the patient was modestly unstable, I decided to ride with him in the ambulance. It was the first time I'd been in an ambulance, it was a lot of fun. I was fascinated by the equipment, resources, and capabilities of the vehicle and thoroughly enjoyed the five minute ride. How do you compactly array everything you might need, from an infant to an adult, from trauma to a heart attack? How do you harness things in a moving vehicle? I was impressed. The patient was quite stable and we got him safely to the emergency department.

First image is in the public domain, second image shown under Creative Commons Attribution Share-Alike License, both from Wikipedia.

Failure

In Samuel Shem's House of God, the residents espouse a law of medicine: the patient is the one with the disease. This crude and insensitive statement has a very important purpose: when a bad outcome happens, as it inevitably must, the physician should not (in most cases) be wrought with guilt. Although some people might read the sentence as a grossly mean thing to say about a patient, I recognize what it stands for. We (and especially those of us in intensive care) all have patients who die despite everything we do, get worse despite our surgeries, fare poorly despite our medical decisions. We sometimes question ourselves, but almost always, it is not lack of doctor that kills the patient. It's not a lack of knowledge or dearth of skill. It is simply the ravages of disease and injury and the limitations of what modern medicine can promise. Patients aren't the only ones who expect miracles. Sometimes as physicians, we devote ourselves so entirely, invest ourselves emotionally, physically, and mentally to such an extent that we cannot tolerate failure. And when it happens, we are devastated. We second guess ourselves, question our judgment. Could we have averted a crisis? Were our skills inadequate? Could there be a scenario where the patient sprang back to life?

I recently had the anesthesiologist's nightmare: a patient who could not be intubated, could not be ventilated, and in fact, was a near-impossible cricothyrotomy. Although the patient was a known difficult airway, those of us who respond to codes through the hospital did not know that (as he was not on the medical intensive care service). He has all the risk factors of difficult airway: morbid obesity, obstructive sleep apnea, large neck circumference, poor mouth opening. He also had many inpatient risk factors: recent head trauma, altered mental status, and an intubation course of over a week. After extubation, he developed stridor, and after severe desaturation, the code was called.

Despite all the tricks I and four other anesthesiologists who responded had, despite all our video laryngoscopes, fiberoptic bronchoscopes, different types of LMAs, we could not put a breathing tube into the windpipe. We asked a surgeon to try to access the windpipe by cutting into the neck, but this was complicated by severe bleeding. Even the ear-nose-throat surgeons had tremendous difficult getting to the airway. The patient passed because of an impossible airway, the one thing that gives anesthesiologists nightmares.

My first reaction was to question my decision-making and my skills. And although I know there are a lot of things I could improve, and perhaps the right person could have put the breathing tube in, after talking to all the other anesthesiologists, I was reassured that I had no glaring errors or deficiencies. I was reminded that despite the importance of reflecting on our clinical experiences - and especially - failures, we cannot be locked into the idea that we are guilty and at fault for everything that goes awry. When I say the patient has the disease, I don't mean anything bad about the patient, but simply that he had an injury or disease process that lead to a code blue. As an ICU fellow, I was simply a responder who put all my heart, skills, acumen, and ability for over an hour in resuscitating him and it was not enough. At the end, we held a moment of silence for his passing.

Judgment

"Good judgment comes from experience, and experience comes from bad judgment." So much of what we do in medicine is by gestalt, recognition of patterns, and clinical hunches. This never made much sense to me when I was young and naive, but after a few years of experience, I'm starting to develop that hard-to-pinpoint decision making where my gut tells me something just doesn't feel right. I'm learning to trust in it and finding that more often than not, it guides me in the right direction. The intensive care unit is full of these quandaries, and spending month after month here, I'm recognizing that I don't know all that many more facts now than I did a year ago, but the experiences I've had really put some perspective and depth into my clinical judgment.

Work

In How Google Works by Eric Schmidt and Jonathan Rosenberg, the authors make an argument against work-life balance, a common phrase thrown about in medical education. They think that work should be an integral part of life, that a manager's job is not to create work hours that allow an employee to maintain free time outside work, but rather to transform work into an engaging, fun, and indispensable activity for the "smart creative" employee. And perhaps in Silicon Valley's tech industry, this is possible, with workplaces brimming with infinity pools, relaxation pods, gourmet meals, and a culture that meshes identity and one's job. I think we are still far from that in medicine and especially medical education. In this spectrum, I am actually very different than my colleagues; I am closer to Silicon Valley's ideal vision of work than my co-residents and co-fellows. I love it and going to work energizes me. I stay late, I don't mind doing more, I search out new opportunities and experiences, I try to pass my passion onto the medical students I teach. Especially as I go further in training, I get closer to the crazy statement in House of God that interns fight over each admission because it gives them another chance to show how good of a doctor they are. We all know doctors who clock in and clock out, who avoid any extra work, who shun admissions, who find the easy way out. And sometimes I can commiserate; burn-out is widespread, and sometimes we just wish we picked a job where we could see our family each night or make plans for every weekend. In any case, this blog is simply an outpouring of reactions as I realize I've finished my last 24 hour in house weekend call but also got "volunteered" to take an extra overnight shift due to a scheduling error. It's funny to understand my reactions: I had a great sense of relief with the former but gave a shrug with the latter.